Doctor as quarterback can improve care, reduce costs

After Jen Singer was diagnosed with non-Hodgkin’s lymphoma seven years ago, she endured six rounds of chemotherapy and five weeks of radiation. That’s physically and mentally draining. But she faced an unexpected burden, too.

“When you are dealing with the side effects of treatment, you are often sent to other doctors,” she said. “Every time I saw a new doctor, I had to give them my medical history.” And oncology patients have long and complicated histories. “One of the hardest parts for me, really, was having to explain everything, again and again, to new doctors.”

A new idea is catching on in health care called patient-centered medical homes. The idea is simple: help doctors better synchronize care across multiple specialties. In Jen Singer’s case, a patient-centered view would help each doctor see Singer’s full medical history via shared electronic records. This fuller view has great potential to improve care (no dangerous drug interactions, for example) and lower costs (no duplicate tests and less guesswork).

In the patient-centered medical home model, the patient’s care is directed by one doctor. While the patient may see other doctors, the main doctor (or “coordinating physician”) directs referrals, tests and care plans and receives the results. With a single doctor at the helm, less information can fall through the cracks. This sort of care delivery could have helped a patient like Singer.

(This model may sound a little like the primary-care gatekeeper of the HMO era. The difference is that the new model’s economic engine aligns the goals of doctors, payers and patients so that doctors are paid for delivering good results for their patients.)

A review of outcomes for this care model in the journal Pediatrics in 2004 concluded that it was associated with “better health” as well as “lower overall costs of care and with reductions in disparities in health.”

Other studies have shown that this sort of integrated care improves the flow of information across providers and leads to fewer medical errors, fewer emergency room visits and fewer duplicate tests. And maybe it’s no surprise that patient satisfaction increases.

More complex care needs more coordination
Coordinating cancer care for someone like Singer is complex. Cancer patients may need to see an oncologist, surgeon and radiologist in the first few months of treatment. If they experience significant side effects as the result of treatment, they may need to see a neurologist, pain management specialist or other clinician. They may also seek therapy to deal with the emotional stress of cancer.

“If you think about cancer care, the oncologist really is the captain of the ship,” Michael Kolodziej, Aetna’s national medical director for Oncology Strategies, said. “Many patients with cancer go to the emergency room or get hospitalized during their treatment, but a lot of that could be avoided by educating patients to contact their oncologists first and making sure the oncologists have processes in place to manage the patients to reduce those hospitalizations.”

To successfully adapt the model to oncology, Kolodziej and others have looked to oncologists to provide their perspective about transforming patient care. “We don’t want to tell the doctors what to do,” he said. “We have broad ideas about what results we want, but we need to learn from them how to get there. What does transformation look like to them? They know what will work.”

In November 2013, Aetna, in partnership with Consultants in Medical Oncology and Hematology, PC, launched their first oncological medical home. It was supported by clinical-decision making tools to make communication between doctors easier. Kolodziej and the Aetna team are currently running other pilot studies with different cancer patient populations. While results are preliminary, the team is pleased. “There are important lessons we can learn from these pilots,” Kolodziej said. “I’m confident this is going to help improve quality of care.”

Jen Singer is now cancer-free. But as she recalls her difficulties with her coordination of care, she thinks the medical home model could be a benefit.

“There’s so much going on with treatment,” she says. “I had to remember the types of chemo I was getting. In my case that was six different drugs in the cocktail. Better coordination would be a good thing. Because there’s a lot of information involved with cancer treatment. And it shouldn’t all be coming through the patient.”